The Health Care Blog – Page 634 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

Z-Packing

May 21, 2012• 2

By Rob Lamberts, MD

It was during my residency that the first indication of heart toxicity of antibiotics affected me personally. The threat was related to the use of the first of the non-drowsy antihistamines – Seldane – in combination with macrolide antibiotics, such as Erythromycin causing a potentially fatal heart arrhythmia. I remember the expressions fear from other residents, as we had used this combination of medications often. Were we killing people when we treated their bronchitis? We had no idea, but we were consoled by the fact that the people who had gotten our arrhythmia-provoking combo were largely anonymous to us (ER patients).

Fast forward to 2012 and the study (published in the holy writings of the New England Journal of Medicine) that Zithromax is associated with more dead people than no Zithromax. Here’s the headline-provoking conclusion:

During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002). Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. (Emphasis Mine).

Continue reading…

FOO For Thought

May 21, 2012• 11

By MARYA ZILBERBERG, MD

I cite this favorite quote from Max Planck in my book (and every chance I get):

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.

I think this applies to all walks of life, not just science. Yet sometimes an argument so compelling comes along that, though reluctantly at first, one by one the old guard drop at its feet. This is what happened to me this weekend at the Health Foo Camp in Cambridge, MA.

First, what is Health Foo? Well that was my first question when I received an invitation to attend this strangely named meeting. A Foo Camp is something put together by O’Reilly, the pioneering digital media group. Started 12 years ago, these meetings are thematic gatherings of “Friends of O’Reilly,” hence “Foo,” intended to bring together a diversity of thought about a specific field. The camp that I attended was the second such gathering in the healthcare space, supported in part by the Robert Wood Johnson Foundation, and held at Microsoft’s New England Research and Development Center in Cambridge. How can I ever thank O’Reilly, RWJF and Microsoft for this mind-shifting event?

As I mentioned in my previous post, the attendee roster was so full of luminaries that I frankly wasn’t sure that the invitation had not ended up in my Inbox by mistake. But mistake or not, what a privilege to attend! I spent the weekend getting to know the faces and the substance behind such familiar names as Regina Holliday, Paul Levy, Alan Greene, Ted Eytan, Susannah Fox, Gilles Frydman and others. And what still has my mind spinning is my conversations with people I don’t normally interact with — computational scientists, game designers, food advocates and international public health movers and shakers.

The most risky aspect of this meeting was the very essence of its success: we were to free-range. No agenda was set; space, food and company were provided. The resulting sessions ran the gamut from the usual nerd porn of probability to such far-reaching topics as memory and the role of faith, poetry and the arts in medicine (my personal favorite, where I got to play in the sandbox of participatory painting led by Regina. Take that, left brain!)

I have to say I spent a part of the weekend in a bit of a fog. What is gamification of medicine? What does “deep modularity” mean? But the full impact of such diversity of knowledge did not hit me until I was heading West on the Turnpike away from the meeting in the direction of home. It felt like a deep air pocket, and for a moment I couldn’t catch my breath.Continue reading…

TEDMED 2012: Atul Butte

May 18, 2012• 2

[youtube width=”520″ height=”270″]http://www.youtube.com/watch?v=dtNMA46YgX4[/youtube]

Supporters of the Big Data movement argue that data will change everything, but only once we break down the institutional and technological barriers that prevent us from getting at it. In his talk at TEDMED 2012 at the Kennedy Center, Stanford’s Atul Butte argues that the we already have more than enough to do real science, if only we know where to look.

June: A Big Month For ACO Watchers

May 18, 2012

By GREGG MASTERS

As we trudge forward into various iterations of what and how ‘accountable care’ strategies can be sensibly configured and locally seeded for Medicare, Medicaid as well as commercial markets, attention is often focused on the ‘necessary’ but ‘not sufficient’ contribution(s) from health information technology (HIT). It is rare that a conversation centered on accountable care or ACOs in particular doesn’t shift to HIT, where EHRs, HIE’s (heath information exchanges) or other data banking or connectivity solutions aren’t a material part of the dialogue. Often posited as the central spine enabling the required coordination and integration essential to accountable care, the technology side of the challenge frequently preempts other issues including physician culture, clinical and financial risk management tolerance and sophistication, or the history of successful physician/hospital joint ventures, in the local market.

Yet in the paradigm shift from volume to value via accountability many are focused on the presumptive return expected from consumer empowerment and electronic health information connectivity. Whether couched as informed choice via up-leveled health literacy, e-patient activism, ‘data liquidity’ or the litany of supportive ‘apps’ including mhealth, wireless or other prevention and wellness oriented platforms, the consumer empowerment movement incentivized by HITECH and further challenged via the triple aim quest are energizing many entrepreneurs, healthcare providers and even regulators.

Expand Over-the-Counter Medications? Very Bad Idea

May 18, 2012• 3

By Marc Siegel, MD

The Food and Drug Administration is considering removing prescription requirements for medications that treat common conditions, such as high blood pressure, diabetes, asthma, migraines and high cholesterol. This means that you would be able to go to your local pharmacy, fill out a questionnaire, receive a diagnosis and purchase a medication, all without intervention or direction from a physician.

As a doctor, I think this is a very bad idea. Although it is true that diagnoses are often missed — reports estimate that as many as 7 million diabetics in the U.S. remain undiagnosed — and although easier access to drugs could theoretically encourage patients to take their medications, I am concerned that expanding over-the-counter access will lead to wrong diagnoses with improper treatments, which carry side effects.

Remember, medicine is an art, practiced on an individual basis. A medication that works for one person doesn’t always work for another. I am constantly changing cholesterol or high blood pressure medications for my patients because of unanticipated side effects such as muscle aches or dizziness.

Lack of follow up

What would happen if I weren’t involved to monitor treatments and make necessary changes? The upfront cost savings from cutting out doctors and their office fees will be more than made up by longer term costs of improper diagnoses or unmonitored complications.

Advocates of expanding over-the-counter medications point to aspirin or allergy drugs as examples that have proved successful without a doctor’s prescription. But for every patient who is glad not to have to visit my office for an allergy prescription, I can point to another patient who has suffered side effects like fatigue that he or she didn’t realize were due to that same pill, or where the allergic reaction was due instead to food.

The fact that common painkillers have been available over the counter for decades also doesn’t provide a convincing argument for bypassing prescriptions. Consider that more than 100,000 Americans are hospitalized every year due to bleeding from aspirin or other OTC non-steroidal anti-inflammatory pills, and acetaminophen is the No. 1 cause of acute liver failure.Continue reading…

Pete Seeger’s Blues

May 18, 2012• 24

By Michael Millenson

There I was, going one-by-one through a list of doctor and hospital groups that had volunteered to be one of the “accountable care organizations” authorized by health care reform, when I inexplicably found myself breaking into song. I know: it’s a really strange way to react to ACOs, but bear with me.

You remember, “This Land is Your Land,” don’t you? Written by Woody Guthrie in 1940, it caught the folk music wave of the 1950s, and has been sung ever since by performers ranging from Pete Seeger to Johnny Cash. Odds are you at least know the first verse:

This land is your land, this land is my land

From California to the New York Island

From the Redwood Forest to the Gulf Stream waters

This land was made for you and me.

ACOs are not obviously song-worthy, although they are significant. One of the Affordable Care Act’s signature initiatives, they initially drew bipartisan support as far back as…well, 2010. In April, the government announced that thousands of doctors serving more than 1.1 million Medicare beneficiaries had voluntarily joined ACOs, giving up fee-for-service reimbursement for some patients in exchange for a paycheck that’s based on measurable standards related to high-quality, cost-effective care. They’ve made the switch because it’s the right thing to do and because they’re getting ready for a day when Medicare’s fee-for-service money dries up.

How Doctors Are Trapped

May 17, 2012• 37

By John Goodman

Every lawyer, every accountant, every architect, every engineer — indeed, every professional in every other field — is able to do something doctors cannot do. They can repackage and reprice their services. If demand changes or if they discover a way of meeting their clients’ needs more efficiently, they are free to offer a different bundle of services for a different price. Doctors, by contrast, are trapped.

To see how trapped, let’s look at another profession: the practice of law. Suppose you are accused of a crime and suppose your lawyer is paid the way doctors are paid. That is, suppose some third-party payer bureaucracy pays your lawyer a different fee for each separate task she performs in your defense. Just to make up some numbers that reflect the full degree of arbitrariness we find in medicine, let’s suppose your lawyer is paid $50 per hour for jury selection and $500 per hour for making your final case to the jury.

What would happen? At the end of your trial, your lawyer’s summation would be stirring, compelling, logical and persuasive. In fact, it might well get you off scot free if only it were delivered to the right jury. But you don’t have the right jury. Because of the fee schedule, your lawyer skimped on jury selection way back at the beginning of your trial.

This is why you don’t want to pay a lawyer, or any other professional, by task. You want your lawyer to be able to reallocate her time — in this case, from the summation speech to the voir dire proceeding. If each hour of her time is compensated at the same rate, she will feel free to allocate the last hour spent on your case to its highest valued use rather than to the activity that is paid the highest fee.

Shame

May 16, 2012• 39

By Rob Lamberts, MD

I saw a gentleman in my office recently. He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight. I know that this would just get better if I lost the weight.” He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs. Besides, he was in significant pain, and a lecture about his weight was not in my agenda. I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me. He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him. He was living in shame. Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character. After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don’t like to lecture people on things they already know. I don’t like to say the obvious: “You need to lose weight.” Obese people are rarely under the impression that it is perfectly fine that they are overweight. They rarely are surprised to hear a person saying that their weight is at the root of many of their problems. Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

The Lesion’s Curse

May 16, 2012• 2

By James Salwitz, MD

A frightened Diane called me today. She was in big trouble. Her primary doctor’s office had called with terrible news. The MRI showed Diane had a lesion. Desperate, she reached out to an Oncologist for help.

A lesion? Yes, a lesion. What could that mean? What did she need to do? What was going to happen? With trepidation Diane asked, “Do I have cancer?”

Medicine prides itself on accurate, specific, scientific analysis. We have delineated more than 50 sub-types of lymphoma. We measure toxin in parts per million. We use complex Latin based terms like hemoglobinopathies to describe red blood problems, or ER positive Her-2 negative lobular carcinoma in situ with microinvasion to define a tiny breast cancer. We adjust drug flow in micrograms per kilogram per minute. Thus, you know we have a very specific delineation for “a lesion.”

Nahhhhhhh…. there is no absolute definition for “a lesion.” In fact, if there ever was a useless, confusing and therefore frightening term, it is “lesion.” Perhaps Aristotle said it best, when he explained, “ To say of what is that it is not, or of what is not that it is, is false, while to say of what is that it is, and of what is not that it is not, is true.” Certainly clears things up for me.

The MedicineNet dictionary defines “lesion” as “almost any abnormality involving any tissue or organ due to any disease or any injury.” The emphasis being on “any.” Farlex notes that a lesion might include any “pathology, tubercle, ulcer, wound, harm, hurt, injury, trauma, stigmata, abrasion, excoriation, scratch, scrape, gash, slash, slice, cut, laceration, or (and this is my favorite), bite. “ I suspect that my Aunt Hilda qualifies as a lesion.

The point is this. The term “lesion” fills in the blank in any medical sentence for “not normal.” However, most of us when we hear the term lesion, we think cancer. This is not what lesion means. We use this vague term when we are too apathetic to be precise.

Pills Still Matter

May 15, 2012• 5

By David Shaywitz, MD

Reviewing “The Myth of The Paperless Office” for the New Yorker in 2002, Malcolm Gladwell argued that if the computer had come first, and paper didn’t exist, someone would have had to invent it. Paper, it turns out, is a lot more useful than we typically appreciate.

It occurred to me that perhaps the same might be said of another product we seem to take for granted in the digital age – medicines. (Disclosure: I work at a company that makes them.)

Medicines – you know, those little white pills that everyone loves to critique – are in many cases remarkably effective solutions to very difficult problems; it’s actually kind of amazing how useful some of these products can be. What an incredibly powerful idea – addressing a difficult and complex health problem with a simple pill you can pop before breakfast.

I read a tweet recently asserting that physicians may soon prescribe health apps as an alternative to medications; my initial reaction: good luck with that one. It’s certainly easy enough to envision how magical thinking about the power of health apps will soon be replaced by disappointment as app developers realize something drug makers have known for years: it’s hard to improve health, and it can be very difficult to get patients to stick with a treatment long enough to make a difference.